What is the recommended treatment for bicep tendonitis, specifically regarding steroid injection?

Steroid Injection for Biceps Tendonitis: Treatment Recommendations

Corticosteroid injections for biceps tendonitis should be limited to providing short-term relief only (2-3 injections maximum, spaced 4-6 weeks apart), as they do not improve long-term outcomes and should not be considered first-line treatment. 1

First-Line Treatment Approach

1. NSAIDs as initial therapy

   • Strongly recommended as first-line treatment for biceps tendon pain 1
   • Start with ibuprofen 1.2g daily (safest option)
   • Can increase to 2.4g daily or combine with paracetamol (up to 4g daily) if relief is inadequate

2. Conservative measures

   • Rest and activity modification to avoid overhead movements 2, 3
   • Ice application to reduce acute inflammation
   • Physical therapy focusing on appropriate stretching and strengthening

When to Consider Corticosteroid Injections

Corticosteroid injections should be considered as a second-line intervention when:

• NSAIDs and conservative measures fail to provide adequate relief
• Pain significantly limits function or rehabilitation progress
• Patient needs short-term relief to participate in rehabilitation

Injection Guidelines:

• Limit to 2-3 injections maximum 1
• Maintain 4-6 week intervals between injections 1
• Local anesthetic injections into the biceps tendon sheath may serve both diagnostic and therapeutic purposes 2

Rehabilitation Protocol

The American Physical Therapy Association recommends a phased rehabilitation approach 1:

Phase	Focus	Duration
Initial	Pain control and protected range of motion	0-4 weeks
Intermediate	Progressive strengthening exercises	4-8 weeks
Advanced	Sport/occupation-specific training	8-12 weeks

When to Consider Surgery

Surgical intervention should be considered if:

• Conservative management fails after 3 months 2
• Severe damage to the biceps tendon is present 2
• Pain persists despite 3-6 months of well-managed conservative treatment 1
• Functional limitations significantly impact quality of life 1

Surgical options include biceps tenotomy or tenodesis, with no significant differences in functional outcomes between these techniques 4.

Important Clinical Considerations

• Biceps tendonitis often coexists with rotator cuff tears or SLAP lesions 2, requiring comprehensive evaluation
• The most common isolated clinical finding is bicipital groove point tenderness with the arm in 10 degrees of internal rotation 2
• Ultrasonography is preferred for visualizing the overall tendon, while MRI or CT arthrography is better for intra-articular tendon pathology 2
• Recent evidence suggests platelet-rich plasma (PRP) injections may be effective for refractory cases 5, though this is not yet included in major guidelines

Common Pitfalls to Avoid

1. Relying solely on corticosteroid injections without implementing comprehensive rehabilitation
2. Exceeding recommended number of steroid injections (no more than 2-3)
3. Failing to identify associated shoulder pathologies that may require specific treatment
4. Delaying surgical consultation when conservative measures fail after 3-6 months
5. Overlooking the importance of activity modification and proper biomechanics in rehabilitation

Remember that biceps tendinopathy encompasses a spectrum from inflammatory tendinitis to degenerative tendinosis 3, and treatment should address the specific pathology present.